Peer-to-Peer Sessions

Thursday, November 13, 2014

10:45 a.m. - 12:00 p.m.

A High-Performing Health System’s Journey to ExcellenceParag Agnihotri, MD, Medical Director, Continuum Care, and Vicki DeBaca, Vice President, Health & Provider Services, Sharp Rees-Stealy Medical GroupThis special session will feature the story of the 2014 Acclaim Award recipient. AMGA's most prestigious quality award, the Acclaim Award is presented annually by the American Medical Group Foundation, honoring physician-directed organizations that bring the American healthcare system closer to a delivery model in which patients experience care that is safer, more reliable, more responsive, more integrated, and more readily available. The presenters will describe how Sharp Rees-Stealy Medical Group used a collaborative, team-based approach to drive progress toward becoming a High Performing Health System™.

Managing Risk: How the Cleveland Clinic Has Adopted a Population Management Approach to Increase Value in the Care of Its Employees and Their FamiliesJames Gutierrez, MD, FACP, Chair, Community Internal Medicine, and Bruce Rogen, MD, MPH, FACP, Chief Medical Officer, Employee Health, Cleveland ClinicThe Cleveland Clinic is the largest employer in Northeast Ohio, and is self-insured for healthcare coverage for its employees and their dependents. The clinic has implemented a comprehensive, population-based approach to improving quality of care while reducing healthcare costs by tightly integrating and coordinating wellness programs, chronic condition management, and Patient-Centered Primary Care Medical Homes. As a result of this collaboration, there has been a significant improvement in healthcare outcomes for employees and their families, along with a substantial reduction in healthcare costs. Presenters will describe how the program is serving as a model for the ongoing implementation of population management strategies for the clinic's broader patient population.

The Virtual Pre-Op ClinicRandal Moseley, MD, FACP, FHM, Assistant Chief Medical Officer, Quality Medical Director, Hospitalist, Galen Sorom, MD, FACP, Physician Manager Department of Internal Medicine, General Internist, Timothy Barnwell, MD, Anesthesiologist, and Marcus Miller, MHA, Director Contact Center/Population Health, Confluence HealthOptimizing medical risk for elective surgical patients with chronic medical problems is an age-old difficulty. Confluence Health found failures in this arena occurred in three basic ways: the surgeon not recognizing the risk; the primary care physician not adequately preparing for risk that was recognized; and critical communication failures among care team members and between care venues. Through creative use of electronic health record tools and an innovative staffing model, they developed a novel system to reliably address these failure points. The session will detail key features of this "virtual pre-op clinic.

2:00 p.m. - 3:15 p.m.

Advanced Illness Management: Leveraging Person-Centered Care and Reengineering the Care Team across the Continuum to Improve Care Betsy Gornet, FACHE, Chief Advanced Illness Management Executive, Sutter Care at Home, Sutter HealthThe Advanced Illness Management (AIM®) program is a patient-centered, evidenced-based care management program for persons whose life expectancy is 12-18 months. The session will review Sutter Health's impetus for developing the program and the systems approach to designing a new care model. Presenters will outline the characteristics of the AIM model of care, including building a virtual care team across the continuum and effective patient engagement strategies, and will share program outcomes on utilization, cost of care, and satisfaction. They also will review the challenges, opportunities, and next steps in advancing the model.

Data-Driven Healthcare Transformation: Population Health Analytics as the Foundation for Primary Care RedesignSylvia Meltzer, MD, Medical Group Operations and Optimization Director, and Laura Spurr, Director, Medical Group Operations, Aurora Health CarePredictive analytics and population health form the foundation for Primary Care Redesign at Aurora Healthcare. This session will provide an overview of the process Aurora is using to risk-stratify their patients with chronic illnesses and apply appropriate interventions based on risk state. Areas of focus include heart failure and COPD risk populations; optimal utilization of patient-centered medical home nurses and building non-traditional primary care teams; developing a self-improving culture; implementing broad change across a large organization; and ROI in quality as well as financial opportunities. Presenters will provide concrete tactics and processes to achieve improvements in care and operational practice, and discuss challenges, lessons learned, and next steps.

Quality Metrics and Outcome Measures: Driving Change and Innovation through Effective Telemedicine Service DeliveryJim Roxburgh, RN, MPA, Director, Dignity Health Telemedicine Network, and Alan J. Shatzel, Jr., DO Chairman, Department of Medicine, Medical Director, Dignity Health Neurological Institute, Medical Director, Dignity Health Telemedicine Network, Mercy Medical Group, Inc. (CA)Health systems across the country are beginning to understand the value proposition for telehealth and telemedicine service delivery as new economic drivers incentivize population management, quality outcomes, and better value. Many have no or minimal experience in development, implementation, and maintenance of a highly effective, multiple-specialty telemedicine network. Over the last five years, Dignity Health Telemedicine Network has managed change and innovation while rapidly adopting new technology for care delivery across the entire continuum. Presenters will discuss quality metrics and outcome measures, including dashboard development and continuous quality improvement and feedback tools utilized to manage and improve their telemedicine network.

Improving Hypertension Control: Adopting Care Processes of the Measure Up/Pressure Down® National CampaignFrancis Colangelo, MD, FACP, Director of Quality Improvement, Premier Medical Associates; Harold D. Brandt, MD, FACP, Medical Director and Chief Compliance Officer, The Baton Rouge Clinic, AMC; Scott D. Flinn, MD, Chief Medical Officer, Arch Health Partners; and Jamie Reedy, MD, MPH, Medical Director of Population Health, Summit Medical GroupTo guide member groups' progress toward the Measure Up/Pressure Down® campaign goal―80 percent of patients in control of their hypertension by 2016―the American Medical Group Foundation introduced eight evidence-based care processes (also referred to as "campaign planks"). These planks were developed out of best practices from past hypertension learning collaboratives and in consultation with the campaign's National Steering Committee and Scientific Advisory Council. This session will feature interactive, small group discussions organized around each care process, facilitated by leaders from medical groups and health systems that are successfully putting the campaign planks into action.

Using Integrated Claims and EHR Data to Improve Patient Care and Financial PerformanceJoe Kimura, MD, Deputy Chief Medical Officer, and Emily D. Brower, MBA, Executive Director Accountable Care Programs, Atrius HealthIntegrating claims and EHR data is critical for identifying opportunities to reach the Triple Aim for healthcare organizations and their patients. Learn how Atrius Health leverages its data analytics infrastructure to identify interventions and drive change, pushing data out to the providers of care to create local engagement. Presenters will describe Atrius Health's Pioneer ACO initiative and how they identified cost drivers, improvement opportunities, and care tools for geriatric population and cost management.

Managing the Successful ACO: Infrastructure, Physician Governance, Gap Closure, and Network LeakageD. Keith Fernandez, MD, FACG, Chief Medical Officer, Memorial Hermann ACO, President and Physician in Chief, MHMDThe Memorial Hermann Physician Network project resulted in over $33 million in shared savings. How? A robust clinical integration program, a highly aligned physician network, information technology, and quality and financial alignment were each a necessary component in their journey towards becoming a High-Performing Health System™. This presentation will describe the steps the Memorial Hermann Physician Network took that led to a successful implementation of the ACO model in both MSSP and commercial vehicles.

HMG Extensivist Clinic: Disruptive Innovation and a Novel Healthcare Delivery ModelChristopher Neglia, DO, Lead Extensivist and Hospitalist, Holston Medical Group"Disruptive Innovation" describes a novel healthcare delivery model where a subset of patients, traditionally hospitalized, is cared for within an office-based clinic. This Extensivist Clinic has no beds and no overnight stays; however, what it provides is prolonged care to the sophistication level of a general medical floor in a hospital. The session will describe how the condensed daytime treatments aim to avoid many of the generalized risks associated with Krumholz's Post-Hospital Syndrome.